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Does this patient have prodromal psychosis?

Evaluate your patient’s thinking by asking, ‘Do you feel that you or people around you have changed in a way you can’t explain?’

Vol. 6, No. 6 / June 2007

Schizophrenia prodrome is an early or prepsychotic state that is a deviation from an individual’s usual behavior and experience.1 Prepsychotic patients can differentiate reality from fantasy but gradually lose this ability as their illness progresses.2 Therefore, early identification and treatment of prepsychotic adolescents and those with early psychosis can reduce social withdrawal, isolation, and psychosocial morbidity and mortality.

Detective work

Probing for possible paranoia and psychotic symptoms in adolescents who do not present with these complaints can be challenging. Maintain rapport as you probe for unusual thought content and delusional ideas by inquiring about your patient’s “experiences” rather than the more pejorative term “problems.” Some prodromal patients may be at imminent risk of conversion to psychosis and continued deterioration. The following questions that are based on prodrome assessment scales1,3 can help detect emerging psychosis.

Thinking can be evaluated by asking:

  • Do you feel that you or people around you have changed in a way you can’t explain?
  • Do people seem alien or evil?
  • Have you been confused about whether something is real or imaginary?
  • Do you daydream a lot?
  • Are you preoccupied with stories or ideas?

Suspiciousness and persecutory ideas can be identified by asking:

  • How are others treating you?
  • Do you feel that people think about you in a negative way?
  • Do you feel singled out?
  • Do you feel that you must be vigilant around others to be safe?

Paranoid adolescents might say they have roommates, friends, coworkers, and family, but detailed questioning may reveal no social interaction. Ask the patient:

  • How do you spend your free time?
  • How often do you talk with friends and family?
  • What groups do you participate in?
  • How friendly are others at school or work?

Also, ask about the meaning of any unusual clothing, tattoos, makeup, or jewelry. These may yield clues about the patient’s perception of his or her identity and social ties.

Ask your patient about computer use, especially favorite Web sites and electronic games. Some alienated and schizoid adolescents may be heavily involved in role-playing fantasy electronic games.4 Loners may fill their free time in cyberspace.

Perceptual abnormalities and hallucinations can be determined by asking:

  • Do you ever feel your mind plays tricks on you?
  • Do you hear unusual sounds?
  • Do you ever hear your name being called when no one is there?
  • Do you feel a presence around you?
  • Do you ever see people or things but realize they may not be real?

Emotional expression and experience of self can be evaluated by asking the patient:

  • Do you feel numb?
  • Do you feel disconnected from yourself or your life, as if you are a spectator?
  • Do you lack rapport with others?
  • Are you bored?

The patient may present with diminished facial expression, monotone speech, and decreased gestures. Conversation might feel stilted with minimal emotional expression.

Estimate deteriorating role functioning by inquiring about problems completing assignments and impaired tolerance of normal stress.

  • Do you avoid or feel overwhelmed by situations that previously you could deal with?
  • Is it harder to get through the day?
  • Are you easily thrown off by unexpected events?

Finally, pay attention if your intuition tells you the patient’s presentation is unusual and possibly psychotic. This ability is called “praecox feeling.” A recent study of praecox feeling showed that the precision of psychiatrists’ intuitive reasoning in early identification of schizophrenia was remarkably high compared with standardized diagnostic classification.5 Cognitive impairment, mood disturbances, disturbed self-perception, and reduced communication abilities all correlate with intensity of praecox feeling.


1. Yung AR, McGorry PD. The prodromal phase of first-episode psychosis: past and current conceptualizations. Schizophr Bull 1996;22:353-70.

2. Tully E, McGlashan TH. The prodrome. In: Lieberman JA, Stroup TS, Perkins DO, eds. The American Psychiatric Publishing textbook of schizophrenia. Washington, DC: American Psychiatric Publishing, Inc.; 2006:341-52.

3. McGlashan TH, Miller TJ, Woods SW, et al. Instrument for the assessment of prodromal symptoms and states. In: Miller T, Mednick SA, McGlashan TH, et al, eds. Early intervention in psychotic disorders. Amsterdam: Kluwer Academic; 2001:135-49.

4. Allison SE, von Wahlde L, Shockley T, Gabbard GO. The development of the self in the era of the internet and role-playing fantasy games. Am J Psychiatry 2006;163(3):381-5.

5. Grube M. Towards an empirically based validation of intuitive diagnostic: Rumke’s “praecox feeling” across the schizophrenia spectrum: preliminary results. Psychopathology 2006;39(5):209-17.

Dr. Tully is assistant professor of psychiatry, University of New Mexico, Albuquerque.

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